Application for ICAP

Federal Aviation Safety Officer Certificate

Initial Certificate and Renewal Letter Requirements

Fill in the blanks as appropriate

Name: ______

Agency: ______

Address: ______

City: ______

State: ______Zip Code: ______

Telephone: (______)______FAX: (______)______

Email Address: ______

Current Federal Agency Aviation Safety Program Assignment:

NOTE:

Applicants for the initial certificate must have completed at least 24hours of training encompassing training in all the course elements listedbelow. To maintain active status an ICAP Federal Aviation Safety Officer Certificate holdermust be actively engaged in a Federal agency aviation safety program, andcomplete 16 hours of Aviation Safety Officer course elements within 24 calendar months. The24 calendar months begin from the date a Federal Aviation Safety Officer first completes theinitial requirements for the certificate and includes each subsequent 24calendar-month period.

Aviation Safety Course Information (fill in blanks as appropriate):

Please list applicable experience, course name and location if appropriate, andhours of training. Use a separate sheet if necessary. Copies of coursecompletion certificates, job descriptions, etc. must be included with theapplication in sufficient detail for review by the Safety Standards and Training Aviation Safety Officer Selection Group.

  1. Basic Aviation Accident Investigation: ______

______

  1. Human Factors: ______

______

  1. Risk Management: ______

______

  1. Aviation Safety Program Management: ______

______

  1. Legal Aspects of Aviation: ______

______

  1. Other courses and experiences: ______

______

Application for the ICAP Federal Aviation Safety Officer Certificate

TO BE COMPLETED BY APPLICANT

“I hereby apply for “initial” or “renewal” (circle initial or renewal) the ICAP Federal Aviation Safety Officer Certificate. I certify that the information contained in this document is correct.”

Applicant’s Signature and Date of Signature:

______

TO BE COMPLETED BY APPLICANT”S IMMDIATE SUPERVISOR

“Certify that the applicant listed above is currently assigned to a Federal agency aviation safety program and I support his or her application for the ICAP Federal Aviation Safety Officer Certificate.”

Applicant’s Immediate Supervisor’s Signature and Date of Signature:

______

TO BE COMPLETED BY APPLICANT’S ICAP REPRSENTATIVE

“I am aware that the applicant listed above is currently assigned to a Federal agency aviation safety program and I support his or her application for the ICAP Federal Aviation Safety Officer Certificate.”

Applicant’s ICAP Representative’s Signature and Date of Signature:

______

TO BE COMPLETED BY ICAP SAFETY STANDARDS AND TRAINING SUBCOMMITEE

Place a check by the appropriate response:

Approved ______

Disapproved ______

Safety Standards and Training Subcommittee Aviation Safety Officer Certificate Selection Group

Attach rational for decision on a separate sheet of paper if appropriate.

Chair of the Safety Standards and Training Subcommittee’s Signature and Date of Signature:

______

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